Provider Demographics
NPI:1275729832
Name:FENDER, TRACEY JOANNE (PNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:JOANNE
Last Name:FENDER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 NORTH MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045
Mailing Address - Country:US
Mailing Address - Phone:928-283-2679
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2858363LP0200X
NH064991-23363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2271333OtherSTATE
AZAP2858OtherAZ STATE BOARD OF NURSING
NH064991-23OtherSTATE